Healthcare Provider Details

I. General information

NPI: 1841586450
Provider Name (Legal Business Name): CHAD ALLEN PURNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 N OAK PARK AVE
CHICAGO IL
60707-3351
US

IV. Provider business mailing address

PO BOX 8500 LOCKBOX 7642
PHILADELPHIA PA
19178-7642
US

V. Phone/Fax

Practice location:
  • Phone: 813-281-8115
  • Fax: 813-281-8656
Mailing address:
  • Phone: 724-433-1645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number125060058
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number036.135966
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: